Dedicated service major advance in doctor health

The AMA is on target to establish a national network of dedicated doctor health services by the end of 2016, Vice President Dr Stephen Parnis has revealed.

In a major speech to the biennial Australasian Doctors’ Health Conference, Dr Parnis said the establishment of the network was a “very significant and positive initiative” that would boost the level of support to the profession.

Focus on the health of doctors, particularly their mental wellbeing, has intensified in recent years amid mounting concerns around very long and disruptive work hours, substance abuse, and workplace bullying and harassment.

The issue of workplace bullying and harassment has come in for particular attention in recent months after vascular surgeon Dr Gabrielle McMullin complained that female trainees were being pressured for sex by senior surgeons.

A survey of 3500 people subsequently conducted by the Royal Australasian College of Surgeons found about half of surgeons, trainees and international graduates had suffered some form of abuse. In all, around 60 per cent of women reported they had been bullied and around 30 per cent said they had been sexually harassed.

Dr Parnis told the Conference that he had personal experience of the many serious stressors doctors face during their working life, and the growing willingness to acknowledge and address them was a welcome development.

“I have been an advanced trainee in surgery, and I have had personal experience of some of the issues uncovered this year,” the Vice President said.

“I have sought the advice and care of medical colleagues when I have found the pressures of my career overwhelming [and] I have grieved for friends and colleagues who have harmed themselves or taken their own life.”

Dr Parnis told the Conference that, rather than indulging in a culture of finger-pointing and blame, the medical profession needed to promote good health and health lifestyles for its members.

He said the establishment of a national network of dedicated doctor health services was an important part of this process.

The Medical Board of Australia is providing the AMA $2 million a year, indexed to inflation, to establish and oversee a nationally consistent suite of health, advice and referral services for doctors and medical students available in all states and territories.

To deliver this, the AMA has created Doctors’ Health Services Pty Ltd, a wholly-owned subsidiary, to co-ordinate the delivery of services that are at arm’s length from the Medical Board.

An Expert Advisory Council, chaired by Dr Kym Jenkins of the Victorian Doctors’ Health Program and including representatives of existing health services, medical students and doctors in training, will help guide its development and operations.

Dr Parnis said the development of the national service was “progressing well, and the programs are on target to be operational by the end of next year”.

“We will all end up being a patient at times during our career, and the challenge is to practise what we preach to our own patients,” the Vice President said. “We need to be honest, to be open to uncomfortable advice from our doctors, and to recognise our own limitations.”

He said the development of the national doctor health service was “a very significant and positive initiative” that would boost the support available to doctors.

“To care for one’s colleagues is not an easy thing, because it entails significant risk,” Dr Parnis said, “but there are real rewards and satisfaction for those who do.”

Adrian Rollins

The dangers of diagnosing cystic neck masses as benign in the era of HPV-associated oropharyngeal cancer

Clinical record

A 59-year-old woman presented to her general practitioner with a lump in the left neck. She was a non-smoker, non-daily drinker and had no significant past medical history. Fine needle aspiration biopsy (FNAB) was performed and led to the diagnosis of a branchial cleft cyst. The mass collapsed after aspiration and the patient was managed conservatively by observation. In the year after diagnosis, re-emergence of the mass was noted by the GP at follow-up. Further investigations were declined on the patient’s presumption that the lesion was a benign branchial cleft cyst.

Two years after her initial diagnosis, the patient re-presented with a 1- to 2-month history of a sore throat and further increase in the size of the neck mass. On examination, a 7 cm mass was palpable, there was no overlying skin invasion and the mass was mobile to deep structures. Repeat FNAB of the neck mass was performed and revealed squamous cell carcinoma (SCC) with p16 positivity.

A staging computed tomography (CT) scan detected a lobulated tumour centred on the left tonsil invading the vallecula, base of tongue and parapharyngeal space. Further, a 27 mm cystic mass consistent with her initial lump was identified in the left level II group of lymph nodes, with additional necrotic nodes present at levels III and IV. A subsequent positron emission tomography scan confirmed increased uptake in these regions.

The patient was diagnosed with a T3 N2b M0 oropharyngeal SCC and was referred for radical chemoradiation. Expression of the surrogate marker p16 on cytological testing was highly suggestive that this was a human papilloma virus (HPV)-positive oropharyngeal SCC.

This case illustrates the diagnostic challenges faced in differentiating cystic nodal metastases from branchial cleft cysts, in the context of the increasing prevalence of HPV-related oropharyngeal SCC in Australia over the past two decades.1

HPV-related oropharyngeal SCC differs from traditional head and neck cancer in both its aetiology and clinical features; and because it is a relatively new clinical condition, GPs, radiologists and pathologists often do not recognise it as a potential diagnosis. Unlike traditional head and neck cancer, it occurs in a younger population who are frequently non-smokers and not heavy drinkers. Clinically, it most frequently presents with a neck mass, and often primary lesions are not easily discernible, as they are commonly small and in clinically difficult areas to examine, such as the base of the tongue or tonsil.

The natural disease pattern of oropharyngeal SCC is to metastasise to the cervical lymph nodes. In the setting of HPV-related cancer, these nodal metastases are frequently cystic in morphology and, as previously indicated, are frequently the first mode of presentation.2 Given the differing clinical features of HPV-related oropharyngeal cancer compared with non-HPV-associated oropharyngeal cancer, it is not uncommon for these nodal metastases to be misdiagnosed as branchial cleft cysts, as described in this case report. The proportion of metastatic SCCs in cysts initially presumed to be of branchial cleft origin has been reported to range from 11% to 21%.3,4

Misdiagnosis can negatively affect patient prognosis as it delays treatment, allows for further disease progression and increases the potential for metastatic spread. Alternatively, proceeding to excisional biopsy of a cystic mass suspected to be a branchial cleft cyst without adequate investigation for an occult primary can lead to tumour spillage into the surrounding tissues.

Differences in the demographics between branchial cleft cysts and cystic nodal metastases may aid clinicians in accurate diagnosis. While branchial cleft cysts may occur at any age, they most commonly present in early adulthood in the second and third decade of life.5 The reported mean age for cervical cystic masses histologically confirmed as branchial cleft cysts ranges from 32 to 37 years.6,7 In contrast, cystic nodal metastases present later, with a reported mean age ranging from 53 to 57.8 years.6,7 Particular attention must be paid to cervical cysts in patients over 40 years of age, as 44% of cystic masses in this patient population are reported to be malignant in origin.8 The most commonly represented lesions associated with cystic metastases are HPV-related head and neck cancer and thyroid papillary carcinoma.9

CT is a mainstay in the diagnosis and staging of head and neck cancer and plays an important role in differentiating benign lesions of the neck from malignant cystic lymphadenopathy. On contrast-enhanced CT, there is homogeneous attenuation throughout the substance of branchial cleft cysts.6 Features suggestive of malignancy include the presence of septations, heterogeneous attenuation and extracapsular spread.6,7 Significant overlap between the radiological features of benign and malignant cysts is, however, present. Repeated local infection involving a branchial cleft cyst may confer a radiological appearance similar to that of nodal metastasis of an SCC.7 In one study, 31% of cystic nodal metastases were reported as benign in appearance, while 38% of branchial cleft cysts had aggressive features mimicking nodal metastases.6 Evidently, isolated use of CT in evaluating a cystic neck mass confers a high degree of misdiagnosis.

FNAB cytology is the current standard of care in diagnostic workup of solid masses of the neck and is reported to have an overall sensitivity of 92% and a positive predictive value of 100% for head and neck carcinomas.10 Unfortunately, this has not been the common experience with cystic lesions, for which its role remains controversial. Reported sensitivities range from 33% to 55%,11 with a false-negative rate of up to 50%.2 The aspirate of cystic metastatic nodes may be difficult to interpret as a result of hypocellularity from the dilutional effect of the cyst fluid.2 There is commonly an associated inflammatory reaction within the cystic nodes, resulting in large quantities of degenerating epithelial cells, inflammatory cells and cellular debris within the aspirate. These cytological features overlap considerably with those of branchial cleft cysts12 and can lead to misdiagnosis.

Despite these limitations, FNAB still retains some relevance in the diagnosis of cystic lesions. Further, with the emergence of molecular analysis techniques, the detection of HPV DNA and thyroglobulin within fine needle aspirates may facilitate the pathological diagnosis of malignant cystic lymphadenopathy and detection of occult primary tumours. The presence of HPV DNA or thyroglobulin in aspirates is strongly correlated with HPV-related oropharyngeal SCC and thyroid cancer, respectively.13,14 Although these tests are primarily used for research purposes at present, their utility may expand to the clinical setting in future to help to differentiate benign and malignant cystic neck lesions.

Differentiating cystic nodal metastases from branchial cleft cysts is an important, albeit sometimes difficult, diagnostic challenge. With the growing prevalence of HPV-related oropharyngeal SCC in Australia, we conclude that metastatic lymphadenopathy should be considered as the primary provisional diagnosis in the adult population with cystic neck masses until proven otherwise. We encourage caution in the interpretation of neck masses as benign by isolated use of either CT or FNAB. Clinicians should use these modalities in conjunction with each other and, if necessary, include referral for an ear, nose and throat specialist opinion to increase diagnostic accuracy.

Lessons from practice

HPV-related oropharyngeal cancer is an increasingly common and relatively new entity that differs from traditional head and neck cancer in its aetiology, epidemiology, clinical features and prognosis.
Lateral cystic neck masses in adults are often misdiagnosed as branchial cleft cysts and should be considered as metastatic lymphadenopathy until proven otherwise.
Isolated use of computed tomography or fine needle aspiration biopsy in evaluating a neck mass can lead to misdiagnosis. Instead, these modalities should be used in conjunction with each other and, if necessary, include referral for an ear, nose and throat specialist opinion to increase diagnostic accuracy.
The emergence of molecular analysis techniques for detecting HPV DNA and thyroglobulin in fine needle aspirates may assist clinicians in the diagnosis of occult primary tumours with cystic nodal metastasis.

[Seminar] Acute-on-chronic liver failure

Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features.

Signs workforce planning getting back on track

It’s been a chequered time for medical workforce planning in recent years.

Health Workforce Australia (HWA) was a Commonwealth statutory authority established in 2009 to deliver a national and co-ordinated approach to health workforce planning, and had started to make substantial progress toward improving medical workforce planning and coordination. It had delivered two national medical workforce reports and formed the National Medical Training Advisory Network (NMTAN) to enable a nationally coordinated medical training system.

Regrettably, before it could realise its full potential, the Government axed HWA in the 2014-15 Budget, and its functions were moved to the Health Department. This was a short-sighted decision, and it is taking time to rebuild the workforce planning capacity that was lost.

NMTAN is now the Commonwealth’s main medical workforce training advisory body, and is focusing on planning and coordination.

It includes representatives from the main stakeholder groups in medical education, training and employment. Dr Danika Thiemt, Chair of the AMA Council of Doctors in Training, sits with me as the AMA representatives on the network.

Our most recent meeting was late last month, and the discussions there make us hopeful that NMTAN is finally in a position where it can significantly lift its output, contribution and value to medical workforce planning.

In its final report, Australia’s Future Health Workforce, HWA confirmed that Australia has enough medical school places.

Instead, it recommended the focus turn to improving the capacity and distribution of the medical workforce − and encouraging future medical graduates to train in the specialties and locations where they will be needed to meet future community demands for health care.

The AMA supports this approach, but it will require robust modelling.

NMTAN is currently updating HWA modelling on the psychiatry, anaesthetic and general practice workforces. We understand that the psychiatry workforce report will be released soon. This will be an important milestone given what has gone before.

Nonetheless, it will be important to lift the number of specialties modelled significantly now that we have the basic approach in place, so that we will have timely data on imbalances across the full spectrum of specialties.

The AMA Medical Workforce Committee recently considered what NMTAN’s modelling priorities should be for 2016.

Based on its first-hand knowledge of the specialities at risk of workforce shortage and oversupply, the committee identified the following specialty areas as priorities: emergency medicine; intensive care medicine; general medicine; obstetrics and gynaecology; paediatrics; pathology and general surgery.

NMTAN is also developing some factsheets on supply and demand in each of the specialities – some of which now available from the Department of Health’s website (http://www.health.gov.au/internet/main/publishing.nsf/Content/nmtan_subc…). I encourage you to take a look.

These have the potential to give future medical graduates some of the career information they will need to choose a specialty with some assurance that there will be positions for them when they finish their training.

Australia needs to get its medical workforce planning back on track.

Let’s hope that NMTAN and the Department of Health are up to the task.

Medicare review taken off course

The AMA has demanded the Federal Government recast its approach to the Medicare Benefits Schedule Review as medical researchers have distanced themselves from claims doctors are routinely ordering ineffective and potentially harmful tests and procedures that are costing the nation cost the nation hundreds of millions of dollars each year.

The AMA has reasserted its support for the Medicare Benefits Schedule Review (and the accompanying Primary Health Care Review) as long as it not only about removing outdated services and procedures, but replacing them with items that reflect modern practice.

AMA President Professor Brian Owler told The Australian Financial Review the medical profession backed efforts to update the MBS but “we’re not going to have a Review that takes money away and puts it on the bottom line of the Budget, and the [Health] Minister [Sussan Ley] says that’s where it’s going. It takes services away from patients.”

The blame game

There has been mounting disquiet over the Government’s handling of the Review, including the depth of consultation with clinician representatives and claims that the vast majority of items were not backed by evidence, and around 30 per cent of all care was of little worth.

Fears about the direction the Government was taking were crystallised on 27 September when Ms Ley launched public consultations by arguing that only a tiny fraction of the 5769 items on the MBS had been assessed for effectiveness and safety, and “inefficient and unsafe Medicare services…cost the nation dearly”.

Issuing the call for consumers to participate in the Review, Ms Ley said that, “30 per cent of expenditure is not necessary, wasteful, sometimes even harmful for patients”.

Professor Owler said the claim was not only “factually incorrect”, but was being used by the Government and the Review Taskforce Chair Professor Bruce Robinson to try and frame the discussion around the idea that there were massive savings to be made because doctors were milking the system.

The AMA President said the figure had been uncritically imported form the United States and there had been no evidence to support it in the Australian setting.

Instead, he said, the Government’s real intention was to use the Review to make Budget savings.

“They need to be upfront about what this process is and that it’s a budget preparation measure,” he told the AFR. “We’re having this conversation and it’s ‘No, no, this is not a cost saving exercise’. But, ‘Yes, the cost savings are going to the bottom line of the budget’. They say ‘Yes, we will reinvest’, but it’s going to be a very protracted, drawn out process to get any money back into MBS.”

Follow the evidence

A day after the Government launched the consultation process, ABC television’s Four Corners program aired claims that doctors were ordering tests and performing procedures that were of little or no benefit for patients and cost the nation hundreds of millions of dollars each year, including scans for lower back pain, spinal fusion surgery, knee arthroscopies and inserting stents in patients with stable angina.

Ms Ley seized on the program, which she said had exposed “real – not perceived – waste in health spending”, and demonstrated the need for the MBS Review.

The Minister said medical specialists and health researchers appearing on the program had “put their professional reputations on the line to provide important insight into billions of dollars being spent on unnecessary, outdated, inefficient and even potentially harmful procedures”.

But two researchers whose work was drawn on in the Four Corners program to help substantiate claims that doctors used inappropriate and unnecessary tests and procedures said their data had been misinterpreted and taken out of context.

Writing in Medical Observer, Associate Professor Helena Britt and Associate Professor Graeme Miller said that although their research showed GPs ordered imaging in about 25 per cent of new cases of low back pain, “conversely, we could equally state that 75 per cent of new cases were not sent for imaging”.

The researchers said that while they did conclude that the rate of imaging for back problems at the initial encounter was inconsistent with guidelines, this was only the case if there were no ‘red flag’ issues present, such as significant trauma, fever, weight loss, inflammatory conditions or advanced age.

“Unfortunately,” they said, “we cannot identify whether or not patients referred for imaging for back symptoms had any of these red flags, but the guidelines suggest that zero imaging for all cases would not represent best quality care.”

Ms Ley rejected claims the Government had launched an attack on the medical profession, and asserted that 97 per cent of MBS items had never been assessed for their clinical effectiveness or safety.

But Professor Owler said the Minister’s claim was “quite misleading”.

While just 3 per cent of items had been assessed through the Medical Services Advisory Committee process, the AMA President said, “but that doesn’t mean that there’s not evidence behind all of the other things that we do”.

He questioned the need for evidence-based reviews for performing life-saving operations: “I don’t need an evidence-based review to say that I should remove the tumour from a child that presents through the emergency department because I know they’re going to end up dead within the week if I don’t do it.”

“There are some things that, yes, we need to evidence-based review, but there are many on the schedule that don’t, and saying that 97 per cent doesn’t have evidence is quite misleading.”

MBS reviews nothing new

He said the medical profession had to be “vigilant” about the narrative being used to shape debate about the Review.

Professor Owler said the AMA not only supported the MBS reviews, but had been engaged with successive governments in undertaking them since 1990. He said in the last five years alone, the AMA had participated in reviews covering 26 areas of the MBS.

“Can we save money? Yes, and the AMA’s more than happy to engage in that process, but let’s actually go through and do the reviews and come up with the evidence before we actually pre-empt what the outcome is and what procedures might have conditions or be removed from the Schedule,” he said.

“The risks to patient care from an emasculated MBS are too great to allow this Review to go off the rails.”

Adrian Rollins

Pressure for independent inquiry of deadly US hospital attack builds

Pressure is mounting on the United States Government to agree to an independent inquiry into its attack on a hospital in Afghanistan that that left 22 people dead following the activation of a rarely-used international investigative body.

The International Humanitarian Fact-Finding Commission (IHFFC), established under the Geneva Conventions, has written to both the US and Afghanistan governments to offer its services for an independent inquiry following a complaint from medical charity Medicins Sans Frontieres, (MSF) which operated the hospital.

US President Barack Obama has issued a public apology for the bombing, and his Government has initiated its own inquiry. But Mr Obama has been steadfast in resisting calls for arms-length investigation, and is considered unlikely to accept the Commission’s offer.

Neither the US nor Afghanistan are member states of the Commission, which has no power to compel their participation.

“It is for the concerned Governments to decide whether they wish to rely on the IHFFC,” the Commission said. “The IHFFC can only act based on the consent of the concerned State or States”.

President Obama has assured that his Government would conduct a “transparent, thorough and objective” inquiry into the tragedy.

But MSF claims the attack could amount to a war crime and must be investigated independently.

“We have received apologies and condolences, but this is not enough. We are still in the dark about why a well-known hospital full of patients and medical staff was repeatedly bombarded for more than an hour,” said Dr Joanne Liu, MSF International President. “We need to understand what happened and why.”

Dr Liu said her organisation was determined to uncover how the attack had occurred, and to hold those responsible to account.

“If we let this go, as if it was a non-event, we are basically giving a blank cheque to any countries who are at war,” Dr Liu said. “If we don’t safeguard that medical space for us to do our activities, then it is impossible to work in other contexts like Syria, South Sudan, like Yemen.

Twenty-two people, including 12 MSF staff, were killed in the hour-long US airstrike, which was called in as Afghan Army units fought to regain control of the city from Taliban insurgents.

MSF nurse Lajos Zoltan Jecs survived the attack and detailed scenes of carnage at the hospital, which was filled with patients at the time.

“I cannot describe what was inside. There are no words for how terrible it was. In the Intensive Care Unit six patients were burning in their beds,” Mr Jecs said.

He told of how surviving medical staff – many badly shaken and traumatised by the blasts – worked frantically to save patients as well as their own colleagues.

“We did an urgent surgery for one of our doctors. Unfortunately he died there on the office table. We did our best, but it wasn’t enough,” he said. “We saw our colleagues dying. Our pharmacist – I was just talking to him last night and planning the stocks – and then he died there in our office.”

President Obama called Dr Liu to apologise for the attack after the US military admitted responsibility.

The attack occurred despite the fact that MSF had given all warring parties the GPS coordinates of the hospital.

Outrage over the attack was heightened when the US initially appeared to claim it was a necessary and legitimate use of force, before later characterising it as a mistake.

MSF said that “any statement implying that Afghan and US forces knowingly targeted a fully functioning hospital – with more than 180 staff and patients inside – razing it to the ground, would be tantamount to an admission of a war crime,” MSF Australia President Dr Stewart Condon and Executive Director Paul McPhun said. “There can be no justification for this abhorrent attack.”

“Medecins Sans Frontieres reiterates its demand for a full, transparent and independent international investigation to provide answers and accountability to those impacted by this tragic event.”

Adrian Rollins

Elective surgery waiting times 2014–15: Australian hospital statistics

In 2014–15: about 700,000 patients were admitted to Australian public hospitals from elective surgery waiting lists; 50% of patients were admitted for their surgery within 35 days; fewer than 2% of patients waited more than a year for their surgery.

Frugal Aussies show US how it’s done

The efficiency and effectiveness of Australia’s health system has been highlighted by figures showing Americans have more chronic illnesses and worse life expectancy than Australians despite spending more than double the amount on care.

Although the United States spent $US9086 per person on health care in 2013, compared with $US4115 in Australia, the average American was likely to live about two years less and be burdened with more chronic diseases, a study by The Commonwealth Fund has found.

As the Federal Government looks to use the Medicare Benefits Schedule Review to cut health spending, the Commonwealth Fund report shows Australia gets good value for its health dollar, achieving high life expectancy and low rates of infant mortality despite one of the smallest outlays among its rich-world peers.

The investigation found the US spent 17.1 per cent of its national output on health care in 2013 – far more than any of the other 12 high-income countries included in the survey. The next biggest spender was France, where the health bill amounted to 11.6 per cent of gross domestic product.

By comparison, Australia’s health care was a bargain. Its total expenditure was the second-lowest among the 13 countries examined – just 9.4 per cent. This was on a par with Norway and only slightly more than the smallest spending nation, Great Britain (8.8 per cent).

Despite this, Australians can expect to live longer than the average American, and in better health. US life expectancy was 78.8 years in 2013, the lowest among the 13 countries examined and considerably less than the 80.1 years for Australian men and 84.3 years for women recorded at the time.

Not only did Americans live shorter, on average, but they were also sicker. The Commonwealth Fund’s 2014 International Health Policy Survey found that 68 per cent of Americans aged 65 years or older had at least two chronic illnesses, compared with 54 per cent of Australians in the same age group. Just 13 per cent had no chronic conditions, compared with 32 per cent of older Britons.

America’s big spending ways are being driven by the adoption of advanced technology and higher service charges rather than because they are constantly rushing to the doctor.

The Commonwealth Fund found that in the US almost 107 MRI exams are conducted for every 1000 people, compared with a rich world average of 50.6 per 1000 and just 27.6 per 1000 in Australia. Similarly, Americans are more than twice as likely to have a CT or PET scan as an Australian.

Not only were they having more scans, they were paying higher prices for them.

Americans also paid the highest prices for medical procedures and prescription drugs. Data from the International Federation of Health Plans indicates that in 2013 bypass surgery in Australia cost an average of around $US42,130, compared with $US74,345 in America, and drugs in Australia were around 50 per cent less expensive.

Not surprisingly, given the relative expense of seeing a doctor in the US (average out-of-pocket costs were $US1074, second only behind Switzerland), Americans were relatively reluctant to seek care. On average, in 2013 they saw a doctor just four times a year, compared with an average 7.1 times among Australians, and the number of hospital discharges per 1000 people in the US was 126 – well below Australia (173 per 1000).

The consequences of America’s heavy health spending are far-reaching, the Commonwealth Fund concluded, not only driving people into bankruptcy and government budgets into deeper deficit, but holding down wages as health insurance eats further into salary packages.

It added that the imbalance in Government spending caused by America’s burgeoning health bill may actually be making the situation even worse.

The Commonwealth Fund warned that American governments were spending so much on health care it was crowding out other areas of expenditure that could actually improve health, particularly social programs and support.

“In the US, health care spending substantially outweighs spending on social services,” the Fund said. “This imbalance may contribute to the country’s poor health outcomes. A growing body of evidence suggests that social services play an important role in shaping health trajectories and mitigating health disparities.”

It suggested one way to redress the imbalance could be through funding arrangements in which providers are rewarded for health outcomes could make it sensible for insurers, hospitals and others to invest in social services and other interventions.

The Commonwealth Fund study can be viewed at: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

Adrian Rollins

Deadly hospital attack could be war crime: MSF

Medical charity Medicins Sans Frontieres says the United States bombing of a hospital in strife-torn Afghanistan could be a war crime, and has insisted it be investigated by an independent commission despite assurances from President Barack Obama that his Government would conduct a “transparent, thorough and objective” inquiry into the tragedy.

As horrific accounts continued to emerge of the devastation wrought by the US bombing of the MSF-operated hospital in the Afghan city of Kunduz, MSF International President Dr Joanne Liu said her organisation was determined to uncover how the attack had occurred, and to hold those responsible to account.

Twenty-two people, including 12 MSF staff, were killed in the hour-long US airstrike, which was called in as Afghan Army units fought to regain control of the city from Taliban insurgents.

MSF nurse Lajos Zoltan Jecs survived the attack and described scenes of carnage at the hospital, which was filled with patients at the time.

“I cannot describe what was inside. There are no words for how terrible it was. In the Intensive Care Unit six patients were burning in their beds,” Mr Jecs said.

He described how surviving medical staff worked frantically to save patients as well as their own colleagues.

President Obama called Dr Liu to apologise for the attack after the US military admitted responsibility.

According to Fairfax Media, White House spokesman Josh Earnest said the US leader told Dr Liu that a US investigation would “provide a transparent, thorough and objective accounting of the facts and circumstances of the incident. And that, if necessary, the President would implement changes to make tragedies like this one less likely to occur in the future.”

But charity has insisted the attack be subject to an independent investigation, and has called for the International Humanitarian Fact-Finding Commission, which has been dormant since its creation under the Geneva Conventions in 1991, to be activated.

The attack occurred despite the fact that MSF had given all warring parties the GPS coordinates of the hospital.

Outrage over the attack was heightened when the US initially appeared to claim it was a necessary and legitimate use of force, before later characterising it as a mistake.

MSF has said the attack could amount to a war crime, and must be fully and independently investigated.

“Any statement implying that Afghan and US forces knowingly targeted a fully functioning hospital – with more than 180 staff and patients inside – razing it to the ground, would be tantamount to an admission of a war crime,” MSF Australia President Dr Stewart Condon and Executive Director Paul McPhun said. “There can be no justification for this abhorrent attack.”

“Medecins Sans Frontieres reiterates its demand for a full, transparent and independent international investigation to provide answers and accountability to those impacted by this tragic event.”

Adrian Rollins

Lust for life, or another one bites the dust?

Patients might be forgiven for feeling a little unnerved if “The Final Countdown” is blaring from the speakers when they are wheeled into the operating theatre.

But is it helpful, or off-putting, for those doing the operating? Recent studies suggest both.

A small study, published in the Journal of Advanced Nursing, filmed 20 operations at two British hospitals to observe the music habits of surgeons.

Researchers placed multiple cameras at strategic points around the operating room to observe verbal and non-verbal communication between staff and found that, at times, playing music in the operating theatre can be disruptive and surgeons should think twice about pressing the play button.

Music was played in 16 out of the 20 operations observed, and usually senior doctors were in charge of the play list.

Dance music and drum and bass based music were often played fairly loudly, with popular tracks sometimes cranked up, making talking more difficult. In one operation, a scrub nurse asked the surgeon to turn the music down because she was finding it hard to count how many swabs had been used.

The UK Royal College of Surgeons said if music is played during surgery it must not be distracting.

Lead researcher Sharon-Marie Weldon said that music can be helpful to staff working in operating theatres where there is often a lot of background noise. However, she recommended that there be a considered approach based on discussion or negotiation about whether music was played, the type of music and the volume it was played at.

In a separate study, more than 80 per cent of theatre staff reported that music helped them while carrying out operations.

The study, published in the British Medical Journal late last year, found that music is played between 62-72 per cent of the time in the operating theatres. As with the Journal of Advanced Nursing study, songs were most often chosen by the lead surgeon.

Theatre staff reported that surgical performance was enhanced when music was played, and that it improved communication, reduced anxiety and improved efficiency.

The researchers said that critics often argue that music consumes cognitive bandwidth, reduces vigilance, impairs communication, and proves a distraction when anaesthetic problems are encountered. However, they encouraged surgeons to embrace music in the operating theatre whenever the situation allowed it.

Kirsty Waterford